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Registered Nurses and Licensed Practical Nurses identified by their Manager will
be certified to perform suctioning via endotracheal and/or tracheostomy tubes
in accordance with the policy of the clinical unit.
This material was developed for the use of Saskatoon Regional Health Authority
(SRHA). This material may not be suitable for other agencies. SRHA makes no
warranties or representations regarding this information, and each agency is
urged to update and modify this information for its own use.
Suctioning Artificial Airways Learning Package i
Permission for extensive copying of this learning package for scholarly purposes
may be granted. It is understood that due recognition will be given to the
Coordinator(s) of this learning package and to the Department of Nursing Affairs
in any use of this material. Copying, publication or any other use of this learning
package for financial gain without approval is prohibited.
Requests for permission to copy or to make other use of this material in this
learning package, in whole or in part, should be addressed to:
ACKNOWLEDGEMENTS:
Coordinated by:
TABLE OF CONTENTS
2.0 Theory....................................................................................................... 2
4.0 Appendix
A. Policies ................................................................................................. 12
Recertification is required annually for LPNs who are not performing the
skill regularly.
2.0 THEORY
The need for suctioning varies from patient to patient, and with patient
condition. For example: a patient with pneumonia and copious secretions
may need to be suctioned every 10 minutes to maintain airway patency and
allow for ventilation. On the other hand, a patient without lung disease, who
has been intubated only for ventilation, i.e. neuromuscular disease, may need
to be suctioned only once a shift.
Patients with the following conditions are more likely to react adversely
to suctioning. Suction these patients with caution.
Increased intracranial pressure
Hemodynamic instability
Recent surgery to the chest and pulmonary structures
Pulmonary hemorrhage
Extreme reactive bradycardia (i.e. when the heart rate drops
dramatically in response to suctioning)
Hyperactive airways
Contraindications to suctioning:
Epiglottis and/or croup are absolute contraindication for nasotracheal
suctioning since suctioning can worsen these conditions
Nasal bleeding
Occluded nasal passages
Coagulaopathy or bleeding disorder
Laryngospasm
Irritable airway
Upper respiratory tract infection
Oxygenation
If required, extra oxygen may be given before and after each episode of
suctioning. This is most often done with ventilated patients. In the non-
ventilated patient, extra oxygen can be provided using a manual
resuscitation bag attached to oxygen or increase oxygen flow, if
needed. If extra oxygen is not needed, encourage the patient to take
several deep breaths before and after suctioning.
Hyperoxygenation
Suction Catheter
The catheter size will vary depending on the size of the airway:
Adults #12 – 14 Fr. catheters
CORRESPONDING SIZES
CUFFED/UNCUFFED METAL LAERDAL SUCTION
SHILEY ADAPTOR CATHETER
00 5
0 8
1 8
2 10
3 10
4 4 5 10
4 5 6 10
4 6 7 12
4 7 8 12
6 8 9 12
8 14
10 14
The catheter size should be no more than ½ the diameter of the airway.
If the airway is fully occluded with the catheter it may cause a drop in
Pa02. In addition, large catheters and small interior diameter of artificial
airways, when coupled with higher suction flow rates, produce the
greatest negative airway pressures and alveolar collapse. Catheter size
can contribute to suction-induced atelectasis, hypoxia, intrapulmonary
shunting and decreased lung compliance. Catheters with multiple
openings versus a single opening produce less tissue trauma. (Egan,
1995) The catheter may also stimulate the vagus nerve, resulting in
bradycardia and hypotension. Paroxysmal coughing due to catheter
irritation increases intrathoracic pressure, decreases venous return and
produces transient hypotension and syncope. It also increases
intracranial pressure and reduces cerebral blood flow. Cardiac
arrhythmias may occur due to decrease in myocardial oxygen supply or
Suction Trap
blend when mixed together and therefore the secretions aren’t thinned
for easier suctioning. (Day et al, 2001).
Assess the need for instillation. If required, instill sterile Normal Saline
into the tube, during inspiration:
3 – 5 ml (adult)
Symptoms Prevention
Hypoxemia/Hypoxia Decreased oxygen Limit suction pressure to:
saturation (Sa02 < 90% 100 – 120 mmHg for adults
or below patient’s 80 – 100 mmHg for children
baseline) 50 – 80 mmHg for neonates
Cyanosis Limit duration of suctioning
Cardiac Dysrrhythmias: to:
tachycardia or 10 – 15 sec. for adults
bradycardia Avoid catheters larger than ½
Premature ventricular the diameter of the airway
contractions Manually ventilate as ordered
Cardiorespiratory until pre-suction status
arrest resumes
Hyperoxygenate &/or
hyperventilate prior to
suctioning
Avoid routine suctioning –
suction only as needed.
Limit number of catheter
passes
Cardiac Dysrrhythmias Tachycardia – Assess for hypoxemia
Cardiac Arrest/Death decreased arterial Stop suctioning
oxygen content Administer oxygen
Bradycardia – vagal Manual ventilation as needed
response
Trauma Aspiration of blood Use lowest level of suction
Tracheal mucosal tinged mucous pressure that will be effective
damage Decreased air entry Perform suction procedure
Pulmonary gently
Hemorrhage/Bleeding Avoid forcing the catheter
Symptoms Prevention
against resistance
Do not apply suction while
inserting the catheter
Withdraw catheter slightly (1
cm) before applying suction
Lubricate suction catheter
with sterile Normal Saline
Limit number of catheter
passes
Avoid routine suction –
suction only as needed
Infection: patient, Increased abnormal Use sterile equipment;
caregiver secretions in the solutions
trachea Maintain strict aseptic
Colonization with gram- technique
negative organisms Keep ends of oxygen source
Increased heart rate, clean to reduces possibility of
respiratory rate, and contamination of the oxygen
temperature source
Use gentle suctioning
technique to avoid trauma
Optimal hydration, nutritional
and metabolic status
Avoid routine suctioning –
suction only as needed
Wash hands before and after
procedure
For staff protection: use of
gloves, masks, goggles is
recommended
Hypotension/hypertension Significant change from Stop suctioning
baseline BP Oxygenate and ventilate
Calm manner while
suctioning
Pain control
Atelectasis Decreased air entry Limiting amount of negative
Change in chest x-ray pressure used (see hypoxia
section)
Keep duration of suctioning
as short as possible (see
hypoxia section)
Provide hyperventilation
before and after suctioning
Appropriate size of suction
catheter
Symptoms Prevention
Vagal Stimulation Cardiac dysrhythmias; Maximize oxygenation
most often before, during and after
bradycardias suctioning procedure
Calmly reassure patient
during procedure
Bronchoconstriction/ Change in air entry Administer bronchodilators
Bronchospasm Wheezes auscultated as ordered. May need to do
Paroxysmal Coughing Same as for prior to suctioning or give
hypoxemia routinely
Ventilate patient in “sync”
with patient’s respiratory
effort
Talk calmly and slowly to
patient to calm them
May need to
sedate/chemically paralyze
patient if unable to ventilate
Obstruction Unable to ventilate Call for help (Physician,
patient Respiratory Therapist, other
Unable to suction staff) stat and prepare to
patient change artificial airway
Continue to attempt to
ventilate patient until help
arrives
Increased Intracranial May correspond with May need to give aerosolized
Pressure increased BP & lidocaine (physician’s order)
coughing 15 minutes before suctioning
3.0 REFERENCES
Boutras, A.R. (1970). Arterial blood oxygenation during and after endotracheal
suctioning in the apneic patient. Anesthesiology 32:114.
Scanlan, C.L., Ed. (1995). Egan’s Fundamental of Respiratory Care, 6th Edition,
540 – 574.
1. POLICY
CORRESPONDING SIZES
2.0 PURPOSE
2.1To maintain airway patency by removing secretions or foreign objects from trachea.
2.2 To assist the patient in removing airway secretions when the patient is unable to
expectorate on his/her own.
2.4 To decrease the potential for infection that may result from accumulated secretions.
3.0 PROCEDURE
3.3 Documentation
• Charting on the Progress Record, Flow Sheet, or Ventilator Record, as per unit
policy, should be done following the procedure. Include the following specifics:
• Amount, consistency, colour, and odor of secretions
• If applicable:
• Hyperoxygenation/Hyperventilation
• Instillation of Sterile Normal Saline
• Chest Physiotherapy
• Specimen sent
• Patient’s tolerance of procedure
• Effectiveness of procedure (ie: lung auscultation)
• Patient/family education provided
REFERENCES:
1. Ackermann, M. H. & Mick, D.J., (1998). Instillation of Normal Saline Before Suctioning
In Patients With Pulmonary Infections: A Prospective Randomized Controlled Trial.
American Journal of Critical Care, 7:4, pg. 261-266.
2. Ackerman, M. H., (1993). The Effect of Saline Lavage Prior to Suctioning. American
Journal of Critical Care, 2: 4, pg. 326-330.
4. Elkin, M, Perry, A & Potter, P. (2004) Nursing Interventions & Clinical Skills. 3rd Edtion.
Philadelphia, PA: Mosby. Pg. 760 – 768.
5. Hagler, D. A., & Traver, G. A., (1994). Endotracheal Saline and Suction Catheters:
Sources of Lower Airway Contamination. American Journal of Critical Care, 3: 6, pg.
444-447.
7. Van Hooser, D. T., (2002). Airway Clearance with Closed-System Suctioning. American
Association of Critical Care Nurses.
The respiratory system allows the exchange of carbon dioxide, produced by cellular
metabolism, and life sustaining oxygen. Interference with the functioning of this
system may rapidly result in death.
The respiratory system consists of a network of airways that provide the pathway
for the transport and exchange of oxygen and carbon dioxide. The respiratory
system is divided into the upper and lower airways.
Upper Airway
Consists of the nose, pharynx, larynx and epiglottis
Major functions of the upper airway are:
Conducting air to the lower airway
Protecting the lower airway from foreign matter
Warming, filtering and humidifying inspired air
During inspiration, air enters through the nose where the nasal cilia filter out
impurities such as small foreign particles (dust, bacteria, some viruses).
From the nose, the air passes into the pharynx. The pharynx is subdivided into the
nasopharynx, the oropharynx and the laryngopharynx. These serve as “hallways”
for the respiratory and digestive tracts. They also play an important role in
phonation.
The larynx is the upper portion of the trachea and connects the upper and lower
airways. It is composed of rings of cartilage, connected by membranes and
muscle. One cartilage forms a complete ring and is called the cricoid cartilage,
located just below the thyroid cartilage. The vocal cords lie inside the thyroid
cartilage. The epiglottis, a flexible cartilage attached to the thyroid cartilage,
functions to prevent the entry of foreign material into the airway when a person
swallows. The function of the larynx is voice production.
Lower Airway
Also called the tracheobronchial tree, the lower airway consists of the tracheal, right
and left mainstream bronchi, segmental bronchi, subsegmental bronchi, and
terminal bronchioles. The major functions of the lower airway are:
Conduction of air through the many branches of the airways to the alveolar
level
Provision of the functional mechanism for gas exchange
The trachea extends from the larynx to the mainstem bronchi and serves as a
passage to and from the lungs. Smooth muscle and C-shaped rings of cartilage
protect the trachea and prevent its collapse.
At its lower end, the trachea divides into the right and left mainstem bronchi. This
bifurcation point is called the carina. One mainstem bronchus enters each lung.
The right bronchus is shorter and wider and extends downward more vertically than
the left. Therefore, aspiration occurs more frequently into the right mainstem
bronchus. The bronchi are composed of cartilaginous rings and ciliated mucous
lining which cleanses the tract by carrying foreign material upward in a blanket of
mucous for expectoration or swallowing.
The lungs are located within the thoracic cavity on either side of the heart and
extend from the diaphragm to just above the clavicles. The lungs inflate with
inspiration and deflate with expiration.
The mainstem bronchus, pulmonary blood vessels and nerves enter the lungs at
the hilum, the depression in the medial surface of the lung. The lungs are fully
moveable within the thoracic cavity, except at the hilum (the route of the lungs at
the level of the 4th & 5th vertebrae) where they are anchored by connective tissue
and pulmonary ligaments.
Each lung is divided into lobes. The right lung has three lobes and the left lung
has two lobes. The lobes of the lung are divided into segments. Blood is supplied
by the pulmonary and bronchial arteries.
The lungs are totally enclosed on their outer surfaces by the pleura, a two-layered
membrane. The layer lining the chest wall is called the parietal pleura; that
covering the surface of the lung is the visceral pleura. The two layers of pleura
are continuous with one another and form a closed sac. Normally, there is no
space between them, but rather a potential space called the pleural space. A thin
film of serous fluid lubricates the pleural surfaces to slide smoothly against each
other, and creates a cohesive force that causes the lungs to move synchronously
with the chest during respiration.
The thoracic cavity is the area within the chest wall bounded below by the
diaphragm, above by the scalene muscles, and circumferentially by the ribs,
intercostal muscles, vertebra, and sternum. The thoracic cavity has four
subdivisions:
The right pulmonary space, which contains the right lung
The left pulmonary space, containing the left lung
The pericardial space, which contains the heart and pericardial sac
The mediastinal space, located at the center of the thoracic cavity between
the two pulmonary spaces, and containing the esophagus, trachea, heart,
and great blood vessels
The thorax also plays a role in ventilation. The elliptical shape formed by the ribs
and the angle of their attachment to the spine causes the thorax to expand when
the chest is raised (diaphragm contracting) and become smaller when it is lowered
(diaphragm relaxing).
Mechanism of Ventilation
Ventilation is the movement of air in and out of the lungs. It occurs in two phases.
The movement of air into the lungs, termed inspiration, is an active process
involving contraction of the diaphragm and intracostal muscles of the thorax.
Expiration, the movement of air out of the lungs, is normally a passive process,
occurring as the diaphragm and intercostal muscles relax. The stimulus to breathe
is transmitted to the medulla in the brainstem in response to rising blood C02
concentration or falling oxygen concentration. The message is then directed down
through the vagus nerve to the other central and peripheral mechanisms. As the
message to inhale is recognized by the receptors in the chest, the chest cavity
enlarges. This occurs by the diaphragm constraint and flattening and the
intracostal muscle contracting up and outward. The diaphragm is innervated by the
fourth cervical spinal nerve. Individuals with spinal cord injuries at the level of C4
and higher will be ventilator dependent. Individuals with complete injuries at the
level of T6 require assisted coughing techniques due to lack of diaphragmatic
innervation.
Increasing the capacity of the thorax provides space for lung expansion. Pressure
changes in the intrapleural space and within the lung combine to pull the lungs
open, producing a pressure gradient, which causes air to flow into the lungs from
the atmosphere. Inspiration continues until the pressure gradient between the
atmospheric air and the air in the lungs is equal. Air flow then ceases and
expiration commences as the diaphragm and intracostal muscles relax. The
amount of ventilation that occurs is affected and regulated by:
Respiratory centers in the brain and periphery
Chemicals in the cerebrospinal fluid
PaO2, PaCO2
pH
Other factors such as pain, temperature, emotions, and physical activity
Exchange of Gases
The exchange of gases between the air and the blood in the terminal alveolar
capillary system is part of the process of respiration. Respiration refers to the
exchange of O2 and CO2 in the body within the lungs, between the cells and their
environment, and in intracellular metabolism.
Normal respiration requires:
Adequate O2 concentrations in the alveoli
Adequate amount of haemoglobin capable of binding with O2
Diffusion of O2 from the alveoli in concentrations sufficient to saturate the blood
adequately before it leaves the lungs
Transportation of oxygen to the body cells
Ability of the body cells to use the O2 supplied to them
Gas exchange occurs in the pulmonary alveoli and in the tissues. Pulmonary gas
exchange is affected by ventilation, perfusion, and diffusion. Gas exchange is also
affected by the availability of an adequate concentration of O2 in the inspired air.
Endotracheal Tubes
Is an airway tube inserted into the trachea to ensure patency of the upper airway. It
can be inserted through the mouth using an orotracheal tube, or through the nose
using a nasotracheal tube. Adult tubes are almost always “cuffed” to prevent
leakage, allowing their use with a mechanical ventilator, and decreasing chance of
aspiration of orophayngeal fluid. The cuff is a balloon-like device that circles the
lower end of the tube. It is attached to a very narrow tube which connects to the
pilot balloon. This device allows for cuff inflations and quick determination of the
cuff pressure. Once the cuff is inflated there is not airflow through the trachea other
than that going through the endotracheal tube. The size and depth of tube insertion
depends on the size of the patient.
Tracheostomy Tubes
Universal
Also called the double-lumen or double-cannula tube
This is the most common type of tracheostomy tube
It has three parts:
Outer cannula – can be either cuffless or with cuff and pilot tube
Keeps the airway open
Cuffed Tube – when inflated, this tube seals the airway and prevents
the aspiration of oral or gastric secretions. The cuff directs air through
but not around the tube. It is commonly used when mechanical
ventilation is required.
Cuffless Tube – Usually double-lumen tubes, cuffless tubes are used
for the long-term management of patients. The patients must have
effective cough and gag reflexes to protect themselves from aspiration.
Cuffless tubes are rarely used in acute care.
Inner cannula – Fits inside the outer cannula and is removed regularly for
cleaning if nondisposable. If the inner cannula is disposable, a new one is
inserted each time the old one is removed. It has a universal adapter for use
with a ventilator and other respiratory equipment.
Obturator – is used during insertion of the tracheostomy tube. It is removed
following insertion and replaced with the inner cannula. It’s smooth rounded
end makes insertion less traumatic to the tissues.
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Single Cannula
Slightly longer than the universal tube
It is used for patients who have long or thick necks
This tube usually requires additional humidification to prevent the accumulation
of secretions which could lead to occlusion
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Fenestrated
These tubes have an opening on the posterior wall of the outer cannula, which
allows air to flow through the upper airway and trachesotomy opening.
This air movement allows the patient to speak and produce a more effective
cough. The fenestrated tube is often used during weaning to ensure that
patients can tolerate breathing through the natural airway before tube removal.
It carries the significant risk of tissue overgrowth of the fenestrations and
subsequent tissue trauma upon removal if left in place too long.
Decannulation Plug
It is attaches to the outer cannula after the inner cannula has been removed
It blocks air flow through the tracheostomy tube and directs breathing through
the mouth and nose
To be used only on cuffless tracheostomy tubes or when the cuff is totally
deflated
Cuffed trachostomy tubes must be totally deflated before decannulation plug
is put on
Designed to facilitate tracheostomy tube weaning and voice restoration
It is a universal size – will fit any tracheostomy tube weaning and voice
restoration
It is a universal size – will fit any tracheostomy tube
Can be difficult to put on (patient coughing)
Can be scary the first time for the patient
May have a lot of secretions at first (due to deflation of cuff)
Can eat with plug in place – assess swallow first
Oxygen given via nasal prongs or mask
When not in use – put in sterile container
Clean with soap & water, rinse thoroughly
NAME: DATE:
2)
3)
2. What signs and symptoms indicate a need for tracheotomy or endotracheal tube
suctioning?
1)
2)
3)
4)
2)
3)
5. Complete the following table matching each complication with symptoms and
preventive measures in columns 2 and 3.
2. Trauma of respiratory
tract
3. Infection
4. Atelactasis